Antepartum Haemorrhage Case Study In Journal

Abstract

Antepartum haemorrhage (APH) is defined as bleeding from the genital tract in pregnancy which occurs after 20 completed weeks of gestation. Research surrounding APH and pregnancy outcomes has been mainly retrospective work. It suggests that APH is associated with higher rates of adverse pregnancy outcomes. The objectives of this study were to prospectively study women experiencing APH to ascertain if such pregnancies are truly high risk.

This is a prospective study conducted at Cork University Maternity Hospital, Ireland, from June 2009 to 2010. Cases were identified in the Emergency Room and controls were selected from the National Perinatal Epidemiology Centre (NPEC) database. Visual blood loss charts were used to aid in assessing volume of blood lost and a datasheet was completed on each patient, together with ongoing monitoring of blood loss during inpatient stays.

84 patients were recruited to the original group. 797 patients made up the NPEC exposed group. Data from these groups was compared against 7715 controls identified in the NPEC database. No significant difference in birthweight, mode of delivery, term induction rate or NICU admission rate was found between the groups. Statistically significant differences in rates of preterm delivery were found with a 4-fold increase in preterm birth in the original exposed group when compared with controls.

This study has identified that women experiencing APH are four times more likely to experience preterm birth in that pregnancy. This information is important for both patients experiencing this pregnancy complication and clinicians involved in their care.

This systematic review and meta-analysis of 29 studies involving 4687 pregnant women with placenta previa demonstrated that between 20% and 78% of women screened positive for antepartum hemorrhage (APH). The pooled estimated of the prevalence showed that more than half (51.6%) of pregnant women experience APH. Finding from this study demonstrated that APH was an important problem for pregnant women with placenta previa, and showed wide variation in the prevalence between studies.

To our knowledge, this review was the first time to conduct a meta-analysis reporting APH prevalence in pregnant women with placenta previa. Characteristics of studies that might affect these estimates were further investigated in this study. The pooled risk estimates indicated that survey year and multiparous were significantly associated with the APH prevalence for pregnant women with placenta previa. Given the high heterogeneity, it was best to consider the confidence interval rather than the pooled result. Because the development of APH has been involved in a higher risk of future delivery and greater long-term morbidity, these findings may affect the long-term health of obstetricians.

APH is a major cause of maternal and fetal morbidity and mortality complicating 2–5% of all pregnancies2. It is linked to an increased risk of emergency cesarean section, need for blood transfusion, maternal intensive care unit admission, hysterectomy, septicemia, thrombophlebitis, and even maternal death29,41. It may occur from the placental site, lesions of the cervix or vagina and occasionally fetal in origin1,2. The major causes of APH are placenta previa and abruption placenta. Other risk factors include marginal sinus bleeding, vasa previa, cord velamentous insertion, battledore placenta, cervicitis, genital trauma, tumours, infections, and coagulation defects20,30,42.

As the chief cause of APH in late pregnancy, the overall prevalence of placenta previa has been recently estimated to be approximately 5 per 1000 pregnancies by world region7. Women with placenta previa are at an approximately 4-fold increased risk of second trimester vaginal bleeding42 and some women necessitate preterm cesarean section and hysterectomy for life-threatening hemorrhage. The prevalence of APH reported in studies was considerably different among different countries in pregnant women with placenta previa. It was reported that the prevalence was 89.6% in Croatia11, 66.6% in Canada5, whereas the data was only 33.8% in Egypt40. In prospective studies, the prevalence of APH was 20.7%, 48.3%, 52.1%, and 55.6% in Austria36, Italy38, Saudi Arabia25, and Japan17, respectively. When assessed by geographic region, the prevalence was high in Asia (53.4%), intermediate in North America (53.2%) and Europe (48.5%), and low in Africa (33.8%) in this meta-analysis. In contrast, there were significant differences between Asia and Africa. However, the unbalanced distribution of studies (Asia: 14 and Africa: 1) would be undermined the statistical analyses, so it should be cautious and best to consider the confidence interval rather than the pooled result.

Differences among prevalence estimates in different countries in women with placenta previa may be due to a number of factors. For instance, demographic and socioeconomic characteristics17,29,36, cultural terms22, lifestyles26 and health statuses27 vary greatly between countries at different stages of development. Evidence has existed that normal gestational length was longer in white European than Black and Asian in nulliparous women with singleton live fetuses at the time of spontaneous labour43. With the increase of gestational age, the risk of APH will increase in pregnant women with placenta previa. It has been observed that the mean gestational age was only 34.2 weeks in placenta previa women in Egypt40. In addition, survey year5, sampling source and methods10,38, and sample size22,35 have a profound influence on the prevalence of APH.

Short cervical length, sponge-like echo in the cervix, placenta lacunae, and the lack of a clear zone are currently regarded as risk factors for APH. The APH incidence appears to have increased in relationship to the increasing rate of endometrial damage in pregnant women. Risk factors for endometrial damage include increasing maternal parity, induced labor, artificial abortion and the number of previous cesarean deliveries. This may explain why the positive correlation was found between APH prevalence and percentage of multiparous in placenta previa in our study. However, similarly result was not found in percentage of previous cesarean section. This discrepancy could reflect a lack of statistical power in this system review owing to the small number of studies.

The purpose of this study was to explore the overall prevalence of APH in pregnant women with placenta previa from 1985 through 2016. Interestingly, it was found that a negative correlation between APH prevalence and survey year. It does mean that as time goes on the mean prevalence will be becoming progressively decreased through epidemiological study. Although this review and meta-analysis have not been considered, we speculate that the main reasons for the decreased rate of APH may be the national health care systems and the improvement in diagnostic techniques and obstetric practice. Compared with fragile health care systems, strong health care systems can provide safe, timely, and appropriate cesarean delivery which is required to ensure optimal maternal and neonatal health outcomes in comprehensive emergency obstetric44. Since 2011, it was recommended that women with placenta previa with previous bleeding events should be admitted at or after 34 weeks’ gestation by the Royal College of Obstetricians and Gynaecologists12. The recommendation will decrease the risk of gestational complications (including APH) in pregnant women with placenta previa. However, the exact reasons that may explain this trend need confirmed in future studies.

The systematic review and meta-analysis included 29 studies with a 4687 individuals, and it showed no potential risk of publication bias. The overall quality of the studies included was all acceptable. And, the result of sensitivity analysis was not substantially altered. Nevertheless, limitations should be taken into account when interpreting the findings of this study. Firstly, just 29 articles were included in this meta-analysis, and only one study from Africa. The variability of sample size and unbalanced distribution of studies would be undermined the statistical analyses and estimation of the prevalence at global scale, so it should be cautious and best to consider the confidence interval rather than the pooled result. Secondly, most of publications (25/29) included in this study were retrospective observational studies, which were considered moderate evidence, and so the conclusions drawn in this analysis were restricted by this study type. Thirdly, significant heterogeneity was observed in the study, which was not surprising as heterogeneity often exists in such meta-analysis of overall prevalence45,46,47. Although subgroup and meta-regression analyses did indicate geographic region, survey year, and percentage of multiparous to explain the observed heterogeneity, the remainder among the studies could be unexplained by the variables examined. We propose that other factors, such as lifestyle habits, alcohol or coffee consumption, mental and physical inactivity may influence APH heterogeneity. Further analyses could not be performed, because of the limited information on these aspects. Finally, the results relied on aggregated published data. Further large-scale, multicenter prospective study using a single validated measured of APH in a random subset of participants would provide a more accurate estimate of the prevalence of APH in women with placenta previa.

In summary, in this systematic review, the summary estimate of the prevalence of APH among women with placenta previa was 51.9%, ranging from 20% to 78% depending on the studies. Further research is needed to identify effective strategies for preventing and treating APH among women with placenta previa.